Personal Information Form by Hdj4S2

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									                        --Personal Information Form--
                                       Today’s Date ______/______/______
Name __________________________ (No P.O Box) Address ______________________
City ________________________ State____ Zip _________ Phone (____)____________
Social Security #_______/____/_______ Date Of Birth ___/___/_____ Male (___) Female (___)
Marital Status: M (___) D (___) Single (___) Number of Children living with you.(___)
Have you been convicted of a felony? Yes (___) No (___) County You Live in ______________
Are You Bondable? Yes (___)No (___) Do you agree to a Background check? Yes (___) No (___)
Date you can start _________? Days you will be working for us? (Circle) M. T. W. T. F. S. S.
Employed? Yes (__) No (__) Employer ___________________, Phone (____)_______________
                   Work History- (Please furnish a brief summary on back of this form.)
References: (Please list three not related to you. Please Print)

Name____________________, Address____________________, Phone (______)_______________

Name____________________, Address____________________, Phone (______)_______________

Name____________________, Address____________________, Phone (______)_______________

Nearest relative not living with you. (How Related?) _______________________________

Name____________________, Address____________________, Phone (____)_________________
In case of emergency, notify:

Name____________________, Address____________________, Phone (____)_________________
In the event you become disabled, seriously ill or injured in an accident, who would you have
do your weekly collections until you could resume your duties or, until Family Relief Fund
could find a replacement for you?

Name_______________________, Address________________, Phone (______)____________

Your Signature_________________________ Your E-Mail Address_________________________
      Attach a photocopy of your driver's License to this form. (Be sure the copy shows all details clearly)

Driver License Number _______________________State______(This will be your ID #)

Form #104

                         Copy and Complete these forms then Fax them to 417-991-3200
                             Call Toll Free- 1-800-254-0045 for more information.

								
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